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In such a patient, at this comparatively early stage of the disability, the concentration power is good; she complains of sleeplessness and her friends notice that she is moody and irritable; but the condition is not considered one for medical attention until pain of some kind develops. When such pain does develop the patient has passed from the instinct distortion phase of the disorder.
This early phase may be called the 'neurosis of unsatisfied desire' and its frequent occurrence in single women at the time of the menopause is of interest. I have found it particularly common in childless women approaching the menopause, and especially in schoolmistresses, whose daily work brings them in contact with children. Any individual who wants something badly and is unable to satisfy this want, and especially if this inability is dependent upon self-control, is liable to manifest the above symptoms. It is in my experience a condition more common in females than in males, but it occurs in the latter often enough.
These two conditions, the terror-neurosis and the neurosis of unsatisfied desire, are, so to speak, the elements of the progressive group of functional disabilities of the nervous system and they serve to emphasise the clinical duality of emotionalism. The word 'dysthymia' is a convenient synonym for the more cumbersome 'instinct-distortion neurosis,' and elsewhere I have referred these two groups into 'centrifugal' and 'centripetal' classes respectively.
Now, as one of the results of elaborate emotional control and pictorial memory, there has entered into human psychology the factor of dread, an associate of memorisation. In the course of time the dysthymic patient develops dread; dread of insanity, of malignant disease, of heart disease and, to the lay mind, its inevitable concomitant, sudden death.
Dread is a function of pictorial memory and in the absence of such memory there can be no dread. It is therefore an exclusively human trait and neuroses of which dread is an essential factor are necessarily progressive in type. It is more closely associated with control of the emotions than is fear pure and simple; a patient with the terror neurosis for example tends to develop dread when a certain degree of control has been established. The factor of dread in combination with a certain degree of control is liable to be accompanied by a rising blood-pressure and vascular or 'functional' pain; this may I think be made even more definite. Functional pain is always associated with a rising bloodpressure and the combination of the two postulates the existence of dread.
Many authorities I know will not hold with me here. They will
describe cases, apparently functional, in which the blood-pressure is low, but in such cases my own feeling is that some more frankly pathological 'cause' than psychical maladaptation is operative. It has always been my custom in such cases to institute a most rigid investigation for any possible toxic element; it is to this group of cases that the 'toxic' neuroses are to be found. In this group the predominating symptoms are generally dependent upon a sympathetic nervous system derangement; palpitation; nausea; asthma; abnormal sweating with coldness of the extremities; mucous colitis; pain over the major arterial trunks; subjective abnormalities of balance. Another group of the same kind is the hypochondriacal section of disordered nervous function. In this however we have much pain as morbid sensations other than pain, and sensations of abnormal consistence of different parts of the body.
In the true sense of the phrase, however, these toxic neuroses should not be considered as being functional. Subjective abnormal sensations in the absence of apparent organic disease and in the absence of a rising blood-pressure are in the majority of cases, at any rate, of toxic origin.
We may therefore say that, from the clinical standpoint, emotionalism falls into two groups, centripetal (emotions intimately concerned with reproduction) and centrifugal (those concerned with the safety of the individual apart from the community) and that disordered emotionalism, recognised in the human clinically as a functional nervous disorder, may arise out of
(1) An absolute deficiency of emotional control dating from the earliest years of life and permitting the operation of psychical dissociation which would otherwise have been non-operative.
(2) An abnormal balance of emotional control as devoted to the two groups of emotionalism respectively. (The dysthymias or instinctdistortion neuroses.)
This may take the form of undue control applied to tones of the centripetal order (emotions concerned with reproduction) or to its deficiency in association with the centrifugal variety (subserving personal safety).
(3) Arising out of (2) through the intervention of pictorial memory (which is a function of emotional control among other factors) we have abnormalities in the sphere of dread; the memory- or mnemo-neuroses.
Emotional control being a faculty of the higher animals as compared with the lower, its defective development in the human may be looked upon as a reversion to a lower type of psychology and neuroses arising out of such a defect are retrograde. Hysteria is of course the type of this
state of affairs and hysteria should be considered as a regressive condition. Neuroses, for the formation of which emotional control is necessary, are progressive, and the dysthymias and mnemoneuroses are of this class.
Clinically the two groups of neuroses, retrograde and progressive, are sharply differentiated by the presence or absence of psychical distress.
Hysteria is essentially a protective mechanism, subserving the patient's egocentricity; being in conformity so to speak, with his self-respect. The earliest attacks are associated with a limitation of the field of consciousness and the performance of actions primarily associated with a centrifugal emotional tone provocative at one time of the mechanism of psychical dissociation. In subsequent attacks the abnormal behaviour is more and more habitual and the diminution of consciousness is less and less in degree; hysteria may be considered as the neurosis of habit action. The persistence of hysteria as a clinical state implies the dominance of the patient's egocentricity over his immediate surroundings; characteristically such people are apparently temperamentally placid.
On the other hand, the progressive neuroses implying as they do the inability of the patient to satisfy certain strongly felt emotions, are accompanied by temperamental instability; irritability, depression and so forth. And of the progressive neuroses, the mnemoneurosis is associated with pain.
The inability on the part of an individual to gratify a strongly felt emotion, however much it may conduce to behaviour in accordance with the dictates of the community to which he belongs, carries with it the implication of a psychical 'failure to make good,' and psychically speaking such individuals are failures in the psychical struggle for existence. Just as failures in the struggle for existence among lower animals are rapidly destroyed, so among human beings, in whom the struggle for existence is psychical rather than somatic, psychical failure to make good bears with it the potentiality of premature destruction. This is brought about through the rising blood-pressure and the premature occurrence of arterial involutionary disease; such patients dying of cerebral, cardiac or renal atheroma, one or more.
It is the memory neurosis which in the majority of cases brings the patient with a progressive functional disorder before the clinician, but a careful investigation into the history brings to light the symptomatology of the primary or dysthymic states, centripetal or centrifugal. These two primary states are in reality the elements of the progressive neurosis, upon which the more disabling condition is founded. As has been said above, however, often enough these dysthymic states are not considered Med. Psych. v
so much in the light of illnesses' as of 'perversity' on the part of the patient, and this applies especially to the centripetal variety. (It has been indicated elsewhere that a third dysthymic condition is to be recognised clinically in association with the emotion of anger. This also in the course of time is liable to pass into the memory-neurosis group of disorders.)
Clinically then the psychoneuroses may be classified into the following
A. Retrograde; disorders associated with the abnormal operation of psychical dissociation hysteria and the exaggeration of habit action.
B. Progressive; disorders associated with a defective balance of emotional control as applied to (1) emotions subserving reproduction; centripetal dysthymias, (2) those subserving personal safety; centrifugal dysthymias. These dysthymic conditions tend to develop into the (3) memory neurosis through the intervention of dread.
The final phase, associated with involutionary vascular disease, is the outcome of the progressive group and predisposes to deletion of the individual, as psychically unfit. It is interesting that retrograde conditions by themselves never have this implication.
But now, a point of considerable interest arises. It has been suggested above that hysterical states are associated with the abnormal operation of the process of psychical dissociation and that such dissociation is the rule in the non-human animal psychology and has as one of its effects the non-registration in 'memory' of an incident accompanied by a terrifying emotional tone. That is to say, hysterical people in their psychology approach the non-human type closer in comparison than people who are not obtrusively hysterical and, therefore, amnesia developed in early life for experiences associated with a terrifying emotional tone in them would appear to depend rather on a non-registration of such an experience in pictorial memory than upon a registration subsequently made unavailable for the purposes of such memory by 'repression.' And, as a corollary of this, the more hysterical an individual may be, the more retrograde are his psychological processes and the more his amnesia under these circumstances represents not a repression but a non-registration of the responsible experience. (This non-registration applies to the possiblity of recall in pictorial memory; the associated body behaviour proper to the incident at the time of its experience is perpetuated after the manner discussed above and is liable to form the groundwork of habitual action. But such habitual action cannot according to this view be considered dependent upon a psychical registration
repressed from pictorial memory and capable of a restoration to such memory.)
Take, for example, the case of a small child who is being brought up at home in an environment which does not conduce to emotional control and one therefore which is not subversive to the operation of psychical dissociation. In the event of such a child being thoroughly terrified in, say, an open field, the impulse to run away headlong will tend to be perpetuated in after life as a habit, if, and when, the child again encounters an open field capable of reproducing to a greater or less extent the original environment responsible. Once such a state of affairs has occurred in later life, then the habit of running away from such a field will be maintained by the element of expectation, although with the increased control necessarily acquired by the increase in age, the kinetic action may be restrained and the patient may merely feel the wish to run away or a vague sensation of unhappiness in such surroundings. Such an agoraphobia is genuinely hysterical in its inception, and no psycho-analysis, however skilled, will unearth the 'memory' of the initial incident, because such an incident was not at the time registered in pictorial memory. An approximately accurate conception of the nature of the incident may perhaps be gained by the examiner and by the patient by autosuggestion, but it must always be remembered that appropriateness of behaviour cannot be taken as proving that such behaviour is of necessity dependent upon the apparent incident to which such behaviour is appropriate.
The 'phobias' whose conative activity reproduces that characteristic of one of the primary instinctive activities would appear to fall into this group, of true hysterical behaviour, and therefore to depend upon habitual action and not upon an experience, registered in pictorial memory, dissociated from such memory and capable of ultimate recall to it.
The above statements may perhaps appear to conflict with clinical experience, which goes to show that many cases, even the majority, of patients suffering from obsessive fears, are undoubtedly relieved and even cured as a result of skilled psycho-analysis directed to the end of unearthing the psychical representation of an experience which has been subjected to amnesia. In such cases there can be no possible doubt but that a disagreeable experience has been registered in pictorial memory and has been so forcibly repressed that its recall in such memory is impossible to the patient unaided; with skilled assistance however it can be recalled and when properly presented to the patient the associated behaviouristic abnormalities disappear; the patient is clinically and academically cured.